The knowledge and attitude of father in breastfeeding: a questionnaire- based study

Introduction: The father’s support is most fundamental influence in the breastfeeding process, but attitude and knowledge of men towards breastfeeding has not been given due importance and been rarely explored and studied. Aim: This study aims at evaluating the knowledge and attitude of fathers of neonates about breastfeeding. Materials and methods: Using questionnaire approach a prospective cohort study was undertaken over a period of three months from April 2019 to June 2019 in our medical college hospital. Fathers of 104 neonates born consecutively in our tertiary care centre have been included in the study. Results: A total of 104 fathers were included in the study (n=104). The average of the fathers interviewed was 28.8 years. Most were literate, having completed high school. All fathers agreed that breast feeding is essential. Only 40% felt exclusive breastfeeding to be given. 92 out of 104 (90%) agreed breast feeding is a cheaper option than formula feeds. Surprisingly, only 12 out of 104 (11%) reported any difficulty in breast feeding. Only about 30% had attended antenatal counselling regarding breast feeding though nearly 70% felt fathers have a supporting role in breast feeding. Less than 10% father’s felt they have no role in breast feeding. Conclusion: We conclude that attitude of father plays a major role in making breastfeeding exclusive. Hence knowledge of breastfeeding should be given to fathers as well in antenatal period.


Introduction
Breastfeeding is important to both child and maternal health & wellbeing. Breast milk is essential for somatic growth, modulation of gastrointestinal function, immune ontogeny, brain development, protective against obesity and type 2 diabetes. [1] For the mother, breast feeding suggests to be onco protective, from breast and ovarian malignancy. It also seems have a protective effect from type 2 diabetes and obesity.
Breast feeding improves bonding with the child and spouse and may help to reduce and prevent depression [2]. The role of breastfeeding in causing lactational amenorrhoea and its advantages to the mother specially in natural contraception and birth spacing is well known. Breast milk is the ideal nutrient for the healthy growth & development of infants. World health organisation (WHO) recommends that babies be exclusively breastfed till six months of age [3]. Mother's own milk is the best source of nutrition. In addition to its nutritional advantage, breastfeeding is convenient and inexpensive, and also is a bonding experience for the mother and infant [1]. The American Academy of Paediatrics, Indian academy of paediatrics, Academy of Nutrition and Dietetics all support and endorse this recommendation [2].
Literature reaffirms the protective effect of exclusive breastfeeding during the first six months of life against infectious diseases, with an 88% reduction of mortality. [2]. Further breast feeding is to be continued till age of 2 years along with weaning diet. [3] However, even among mothers from advantaged backgrounds, these recommendations are hardly fulfilled.
Globally, only 38% of infants are exclusively breastfed [1]. The general consensus finding is that infant feeding practices are incongruent with the guidelines [4].
Pediatric Review: International Journal of Pediatric Research Available online at: www.medresearch.in 455|P a g e Numerous studies suggest that breast feeding initiation, exclusivity, support, continuation and cessation are all strongly influenced by the father [5,6]. In pediatric nutrition significant gap between practices and current guidelines is notable only for breast-feeding and use of formula.
Parents do not follow medical professional advice often. The main reason for not adhering to the advice was that they did not consider it suitable for their infant and they preferred to rely on their feelings or recommendations from familiars [3]. The attitude of fathers has been shown to be the important determinants of infant feeding but it is rarely explored.
The participation and the support by father are essential and major predicting factor for interruption of breast feeding [5,7].
The fathers are rarely included in antenatal counselling about breastfeeding. The active involvement and support of father in breastfeeding will help in efficient practice of breastfeeding [6,8]. The present study aims at evaluating the knowledge and attitude of fathers of neonates about breastfeeding and how it influences the outcome of breastfeeding. Study: This is a prospective cohort study. This is a questionnaire-based study, conducted on a pilot study basis using a self-developed questionnaire.

Materials and Methods
Inclusion criteria: All fathers of consecutive live neonates born in our hospital, within 72 hours of life of the newborn. Data collection procedure: The study questionnaire was with 2 parts. The first part consists of questions related to basic information and second part related to breast feeding. The fathers of neonates born inborn within 72 hours of life, were given the questionnaire and the response was evaluated.
Data analysis: Data were entered in MS -excel workbook sheet and was analysed using MS-Excel software. The institutional ethical committee approval was obtained and consent was taken from fathers before participating in the study.

Results
A total of 104 fathers were included in the study (n=104). Father -Age (Av) 28.8 years, most were literate, having completed high school. Neonates-M: F ratio was 1.2:1, 75% born at term, 40% first born (Table 1). All fathers agreed that breast feeding is essential. 78 out of 104(75%) said yes to 6 months duration for exclusive breast feeding. However, it seems most father's consider plain water and bottle formula feeds not contravening this recommendation of WHO. 59 out of 104 (60%) felt plain water should be given while breast feeding and about 47% felt it is good to give bottle formula feeds.
It is important to note that another 45% (46 out of 104) disagreed that bottle formula feeds are good. 92 out of 104 (90%) agreed breast feeding is a cheaper option than formula feeds.
Surprisingly, only 12 out of 104 (11%) reported any difficulty in breast feeding while 72 (70%) responded no and 20 (19%) ticked don't know/ can't say. This response in the early neonatal periods when most nursing mothers report difficulties may indicate the lack of interaction with the new mother minimal involvement of the father in newborn care.
Only about 30% had attended antenatal counselling regarding breast feeding though nearly 70% felt fathers have a supporting role in breast feeding. Less than 10% father's felt they have no role in breast feeding. (Table 2) Pediatric Review: International Journal of Pediatric Research Available online at: www.medresearch.in 456|P a g e The responses for the 10 questions related to breast feeding were as listed in table 2.

Discussion
In spite of WHO recommendation and active promulgation regarding breastfeeding and numerous promotional initiatives, breast feeding practices leave much to be desired even in developed and advanced nations. The status in India is no better despite efforts of government and paediatricians lobbying [3,5,7,8].
The father's Knowledge and Awareness of breastfeeding and its benefits to the mother and to the child has a positive effect in successful breastfeeding [9].
There is very little data available about Indian fathers' knowledge and attitude towards breastfeeding [8].
The average father in the present study was in his late 20s, literate having completed high school. These factors do not seem to influence the overall approach of the father towards breast feeding in the present study. This is similar to findings of study in Mumbai (8)  Most neonates, about 75 % were born at term, 40% first born with a slight male preponderance. This distribution is in line with previous study in Chennai [10].
In the present study, majority fathers, in fact 100%, were aware that breastfeeding is essential and pivotal for the baby. All previous studies confirm that majority fathers are aware that breast feeding is important and beneficial [10]. Mahesh PKB et al in their systematic review and meta-analysis published in BMC Public Health state that most fathers know the importance of breast feeding to mother and baby. 75% agreed that exclusive breast feeding be the nutrition for the baby up to 6 months, similar to various previously conducted studies. However, it has also been reported that fathers had no role in the continuation of breast feeding from 4-6 months.
However, it seems most father's consider plain water and bottle formula feeds not contravening exclusivity. This is an important and significant finding and is an area that needs focus and further future study. Many studies also report of using formula feeds specially in certain situations when breastfeeding might not be possible, unsuitable or inadequate [3,4,11].
In fact, 60% felt plain water should be given while breast feeding and about 47% felt it is good to give bottle formula feeds along with breast feeds.
These findings show a serious gap in knowledge regarding breast feeding concepts that is adversely harming practice and the goal of WHO and paediatricians. The silver lining being that if well informed, fathers would promote exclusive breast feeding in the right way and be helpful in doing away with bottle formula feeds which is in consonance with other studies [10,11]. It is important to note that 45% (46 out of 104) disagreed that bottle formula feeds are good. This is a significant positive finding of the present study [7,9,10,12].
Numerous studies have shown time and again that the world over many women and mother's in general endorse the notion that formula feeds are good and beneficial, at least as supplements alongside breast feeds or as a method to give exhausted and struggling mothers a "break" from their labour. More alarming is the fact that medical professionals like midwives in the UK sometimes promote this and try to hide it and avoid disclosure. The situation in our country may be no different [4,[12][13][14][15][16][17].
92 out of 104 (90%) agreed breast feeding is a cheaper option than formula feeds [12]. This is overall in accordance with findings in developed and developing countries. However, studies in UK among working mothers in low income groups suggest early breastfeeding cessation so that they may get back to work [17].
Only about 11% of the respondents reported any difficulty in breast feeding, while 70% responded and 19% ticked don't know/ can't say. This is a very low rate acknowledging difficulties compared to previous studies in India or abroad [12,18,19].
This response in the early neonatal periods when most nursing mothers report difficulties may indicate the lack of interaction with the new mother minimal involvement of the father in new born care.
In the present study, only one third of the fathers received antenatal counselling about feeding practices. This may be because of the local socio-cultural practices where the partners are not involved in antenatal check-ups [20]. Antenatal counselling should be provided to both parents to sensitise them for exclusive breast feeding. According to American Academy of Paediatrics, the need for paternal education is stressed upon as 11 th step of successful breastfeeding.
The perceived limitations of the present study are as follows.
1. It is a cross-sectional pilot study in which around 100 fathers were included. Larger number will be needed for confirming the findings.
2. The setting of this study is a tertiary care medical facility with neonatal intensive care unit (NICU) attached to our medical college in rural Karnataka on the outskirts of the state capital and IT hub Bangalore.
3. The questionnaire is self-developed, needs further validation.Also, it was administered in the newborn period within 72 hours of birth.
4. Most fathers in the present study were literate. Majority babies were born by caesarean section, thereby the fathers likely to be having more contact with medical personnel and received counselling. Hence the fathers may have been sensitised regarding the benefits of breast feeding and been positively influenced.

Conclusion
Majority of fathers appreciate the benefits of breastfeeding in both maternal and child health. They tend to support mothers in a positive way. More awareness should be brought for exclusive breastfeeding by discouraging other feeds including water. Antenatal counselling should be done involving both the parents as the best time to counsel in the antenatal period.
This study is significant as it provides information regarding the knowledge and attitude father's viz a viz breast feeding about which very little reliable data is available in our country. It also opens up new avenues for future studies as most father's consider plain water and bottle formula feeds compatible with exclusive breast feeding. Investment in antenatal counselling for fathers may yield dividends in the form of exclusive breast feeding for mother and baby.
What this study adds to the existing knowledge?
The breast feeding can be made exclusive only with family support mainly through fathers. The focus of awareness should involve fathers to implement the same.
Author's contributions Dr. Santosh S planned the study, supervised the execution and edited and approved the final manuscript as submitted for publication. Dr. Geetha M contributed through actual execution of the study, developed the questionnaire, critical review and appraisal of literature and drafted the manuscript. Dr. Kiran B was involved in administrative and logistical support for the study, supervised the execution and edited the manuscript.